Becker ENT Center logo Becker ENT Center Schrader Plastic Surgery logo Schrader Plastic Surgery

Becker Rhinoplasty Center

World Renowned Rhinoplasty Surgeon

Central New Jersey
609-436-5740
Southern New Jersey
856-772-1617
  • Home
  • Meet the Doctor
    • In The Media
  • Procedures
    • Rhinoplasty
    • Revision Rhinoplasty
  • Photos & Videos
    • Before & After Photos
      • Bulbous Tip
      • Droopy Nose
      • Ethnic Rhinoplasty
      • Finesse Rhinoplasty
      • Nasal Bump
      • Nasal Fracture
      • Narrow Nose
      • Overprojected
      • Revision Rhinoplasty
      • Saddle Nose
      • Twisted Nose
      • Underprojected
      • Unique Issues
      • Upturned Nose
      • Wide Nose
    • Testimonial Videos
    • Educational Videos
  • Testimonials
    • Patient Reviews
  • Education
    • Nose Form & Function
    • A Patient’s Guide
    • Books & Publications
    • Rhinoplasty Archive
  • Contact Us
    • Locations
    • Sewell
    • Voorhees
  • Patient Info
    • Financing
    • Flying In
    • Choosing a Surgeon
Rhinoplasty Dissection Manual » Chapter 11 – Rib Cartilage Graft Reconstruction of Saddle Deformity

Chapter 11 – Rib Cartilage Graft Reconstruction of Saddle Deformity

The severe saddle-nose deformity may be treated by using autogenous rib cartilage (8,9).

Harvest of rib is described later. The rib graft is carved into a dorsal graft and a columellar strut, which are interdigitated to recreate an intact L-strut (Fig. 6). This type of structural re-construction is particularly useful when there is complete loss of septal support. If an intact nasal septal L-strut is present, onlay dorsal grafting will be sufficient to correct the deformity. Great care must be taken to adhere to the principle of "balanced cross-sectional carving" to minimize the risk of graft warping. Once in position, the domes can be sutured over the graft with a transdomal suture. An external rhinoplasty approach allows exposure for facile placement of these grafts. A tip graft allows improved tip projection and definition.

Rhinoplasty Dissection Manual

Rhinoplasty Dissection Manual Rhinoplasty Dissection Manual

Rhinoplasty Dissection Manual Rhinoplasty Dissection Manual

Rhinoplasty Dissection Manual Rhinoplasty Dissection Manual

Rhinoplasty Dissection ManualRhinoplasty Dissection Manual

Rhinoplasty Dissection Manual Rhinoplasty Dissection Manual

Rhinoplasty Dissection Manual Rhinoplasty Dissection Manual

Rhinoplasty Dissection Manual Rhinoplasty Dissection Manual

Rhinoplasty Dissection ManualRhinoplasty Dissection Manual

Figure 6. A, B: Severe saddle-nose deformity. Rib graft is fashioned into a columellar strut (secured to the medial crura) and a dorsal onlay graft that interdigitates with the columellar strut. Preoperative (C-F) photographs of a patient with a severe saddle-nose deformity. She underwent application of an iliac bone graft to her nasal dorsum in the past. Lack of an intact L-strut and in-adequate middle vault support resulted in descent of the graft, airway obstruction, and referral to our office for re-construction. Base view reveals the bone graft in the left nostril and a widened columellar scar. Graphic operative worksheet (G, H) illustrates the surgical high points. Rib graft was harvested (I, J), and exposure was achieved via the external rhinoplasty approach (K, L). A sutured-inplace columellar strut fashioned from rib graft was secured between the medial crura (M, N). A dorsal-on lay graft was carefully carved (0, P) with a notch, allowing it to interdigitate with the columellar strut. The dorsal graft was placed and se- cured (Q-T). Example from another patient illustrating interdigitation of strut and dorsal on lay graft (U). A tip graft was placed and covered with a layer of perichondrium to camouflage and soften the leading edge of the tip graft. (V, W).

PEARLS

When placing plumping grafts, the surgeon should overcorrect because the grafts tend to settle over time. Additionally, the pocket can be gently irrigated with antibiotic solution to minimize the incidence of infection.

When performing a caudal extension graft, the surgeon must take special care to set appropriate tip projection, rotation, length, and alar/columellar relation. Additionally, the caudal margin of the graft must be in the precise midline.

The inferior border of the caudal extension graft should be stabilized on the posterior septal angle, soft tissue, or other supporting tissues to avoid postoperative counterrotation of the extension graft.

Deviations of the caudal septum can usually be corrected by crosshatching the cartilage and other conservative maneuvers described in the text. Many cases can be corrected by accounting for excessive length of the L-strut. In rare cases, subtotal septal replacement may be necessary.

When using an integrated columellar strut/dorsal graft, the surgeon must take special care to stabilize the columellar strut in the midline to avoid shifting or tilting of the columella. Placement of the dorsal graft into a precise dorsal pocket or suture fixation of the dorsal graft to the middle nasal vault will minimize the chance of the graft shifting to one side.

Symmetric carving of the costal cartilage graft will minimize the chance of the graft warping over time.

REFERENCES

  1. Tardy ME, Becker DG, Weinberger MS. Illusions in rhinoplasty. Facial Mast Sure 1995:1 1:117-138.
  2. Tardy ME. Rhinoplasty: the art and the science. Philadelphia: WB Saunders, 1997.
  3. Toriumi DM. Caudal septal extension graft for correction of the retracted columella. Oper Tech Otolarvngol Head Neck Surg 1995;6:311-318.
  4. Beeson WH. The nasal septum. Otolarvngol Clin North Am 1987 : 20:743-767.
  5. Toriumi DM, Ries WR. Innovative surgical management of the crooked nose. Facial Plast Sti n g Clin North Am 1993;1:63-78.
  6. Metzinger SE, Boyce RG, Rigby PL, Joseph JJ, Anderson JR. Ethmoid hone sandwich grafting for caudal septal defects. Arch Otolarvngal Head Neck Surg 1994;120:1121-1125.
  7. Toriumi DM. Subtotal reconstruction of the nasal septum: a preliminary report. Laryngoscope 1994;104: 906-913.
  8. Daniel RK. Rhinoplasty and rib grafts: evolving a flexible operative technique. Plast Reconstr Stag 1992:94: 597-611.
  9. Wang TD. Aesthetic structural nasal augmentation. Oper Tech Otolar rngol Head Neck Surg 1990.

Related Information:

  • Achieving Surgical Goals: Selected Options
  • Acknowledgements
  • Adjunctive Procedures
  • Aesthetic Analysis
  • Alar Base Resection
  • Alar Wedge Excision
  • Anatomy
  • Chapter 10 – Sliding Alar Flap
  • Chapter 11 – Caudal Extension Grafts
  • Chapter 13 – Placement Of Intranasal Packs, Nasal Splint
  • Chapter 13 – Postoperative Care
  • Chapter 5 – Incisions and Approaches
  • Cleft Lip Nasal Deformity
  • Closure of the Marginal
  • Delivery Approach
  • Deviated Caudal Septum
  • Foreward
  • Guide to Nasal Analysis
  • Harvesting Calvarial Bone
  • Harvesting Conchal Cartilage: Anterior Approach
  • Harvesting Ethmoid Bone
  • Harvesting Rib Graft
  • Indications For External Rhinoplasty Approach
  • Infiltrative Anesthesia Technique
  • Intermediate Osteotemies
  • Lab Exercise: Nasal Analysis
  • Landmarks For Analysis
  • Lateral Osteotoniies And Infracture
  • Appendix M – List of Selected Companies with Address/Phone Numbers
  • Medial Osteotoniies
  • Nasal Dissection: Septoplasty with Cartilage Harvest
  • Photography Setup (1)
  • Plumping Grafts
  • Preface
  • Rhinoplasty
  • Rhinoplasty Analysis
  • Rib Cartilage Graft Reconstruction of Saddle Deformity
  • Selected Complications of Rhinoplasty
  • Spreader Grafts
  • Suggested Surgical Instruments for Rhinoplasty
  • Surface Angles
  • Surface Angles, Planes, and Measurements
  • Surgery of the Nasal Tip
  • Tip Support, Incisions, and Approaches
  • Transcartilaginous or Cartilage-Splitting Approach
  • Tripod Concept

Contact Us

  • This field is for validation purposes and should be left unchanged.

RHINOPLASTY EDUCATION

  • Nose Form & Function
  • A Patient’s Guide
  • Books & Publications
  • Revision Rhinoplasty Textbook
  • Rhinoplasty Education
  • Rhinoplasty Dissection Manual

REVIEWS

"Dr. Daniel Becker is the sweetest most caring person. It’s almost a year since I had a really bad nose bleeds and he was there for us, came to hospital in the snow on a Sunday just to fix me. He is so very special and always there when you need him. Love him!!!"
More reviews »

SERVICES

  • Rhinoplasty
  • Revision Rhinoplasty

LOCATIONS

  • Office Locations
  • Sewell Office
  • Voorhees Office
FacebookTwitter

Copyright © 2017 Becker Rhinoplasty Center. All Rights Reserved.
Medical Marketing by Surgeons Advisor

  • Sitemap
  • Terms of Use
  • HIPAA Privacy Policy
  • Company Privacy Policy
  • Website Privacy Policy